Child and Adolescent Health and Health Care Quality Measuring What Matters (2011) / Chapter Skim
Currently Skimming:
2 Setting the Stage
2 Setting the Stage
Pages 23-66
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The final section offers initial observations that serve as the foundation for the rest of the report. The chapter provides the conceptual basis for addressing the strengths and limitations of current data sets that are used to measure health and health care quality for children and adolescents.
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" Indicators are a collection of individual quality measures, consisting of a denominator and a numerator, that suggest a trend or pattern of health conditions, behaviors, or influences. Indicators of mental health status, for example, may consist of several individual measures of selected disorders, such as depression, attention-deficit disorder, and mental retardation.
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Moreover, those who are concerned with children's health status want to know about more than the presence or absence of specific health problems in the general child population at a given point in time. They also want to know whether children's health improved or diminished as compared with other periods.
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In addition to these domains, that earlier report examines the relationships among a variety of physical, social, and policy influences and health status and outcomes. The IOM committee that developed the report formulated a conceptual model emphasizing the dynamic and developmental nature of children's health, focusing on the role of biology, the physical environment, and social and behavioral determinants in shaping the health and behaviors of children and youth (see Figure 2-1)
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. While this committee endorses an expanded definition of child health, multiple definitions are in use.
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This approach led to a broadening of the concept of child health to include "the ability to realize aspirations, satisfy needs, and change or cope with the environment" (Starfield, 2004, p.
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. In focusing on data systems, the committee endeavored to examine the contributions of existing child health data collection efforts and to assess their relative strengths and limitations (see Chapter 4)
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. BACKGROUND As context for the remainder of the report, this section provides a current snapshot of children and youth in the United States, their health status and trends, and their access to and use of health services.
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populations. Adding more data elements on race/ethnicity, socioeconomic status, special health care needs, primary language spoken at home, and parental English proficiency to administrative data sets for Medicaid and CHIP populations would provide a basis for comparing their health status and the quality of health care services they receive with the health and health care of other populations of children and adolescents.
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Both programs were enacted by the Social Security Act (Titles XIX and XXI) , which also established the Maternal and Child Health Bureau (MCHB)
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. Equity is a feature of the initial health care quality framework set forth in Crossing the Quality Chasm (IOM, 2001a)
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will collaborate to make recommendations for an initial core set of children's health care quality measures (completed January 1, 2010)
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. • T he number of children and youth in the United States identified as having chronic health conditions has increased considerably in the
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children meet the definition of children with special health care needs -- "those who have a chronic physi cal, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally" (McPherson et al., 1998, p.
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Having health insurance, whether public or private is strongly associated with access to health care and use of health services among children (GAO, 1997; Newacheck et al., 1998a; Olson et al., 2005)
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. These facts take on special significance given the strong evidence alluded to above that health status in childhood lays the foundation for health status throughout the life course.
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Another example of a factor influencing health status throughout the life course is childhood obesity. Over the past three decades, obesity has more than doubled among children aged 2–5 and more than tripled among those aged 6−11 and adolescents aged 12−19.
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annual report on the health status and service needs of America's children, tracks health care utilization. Highlights from the 2007 report underscore the differential rates of well-child care among children of different ages, household income, and racial and ethnic backgrounds: • early 26 percent of children under age 18 were reported by their par N ents not to have had a preventive, or well-child, medical visit in the past year, although this number ranges from 17.3 percent of those aged 4 or younger to 36 percent of those aged 15−17.
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Chapter 4 addresses in detail the relationship between childhood events and outcomes observed in adulthood, as well as the intergenerational transmission of health and well-being. Box 2-4 summarizes the role of health care, public health interventions, and clinical preventive services in child health and well-being.
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The Life-Course Approach to Health As noted above, many adult health conditions originate in childhood, and several conditions that occur in childhood impact adult health. A recent IOM report, Leading Health Indicators for Healthy People 2020 ("Leading Health Indicators")
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It also provides a bridge between individual and population health measures, highlighting opportunities for preventive or treatment interventions to have significant effects on the well-being of selected groups. The committee's use of the life-course perspective provides an appropriate lens through which to view measures of child and adolescent health and health care quality.
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that are salient to improving child and adolescent health trajectories. The Life-Course Perspective and Childhood Obesity Childhood obesity, with its associated increased risk for adult obesity and type 2 diabetes, illustrates the value of using the life-course approach.
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The health care system can identify and address certain health conditions and risk factors that have particular importance during adolescence and implications for adult health, including sexually transmitted infections, chronic mental health conditions, substance abuse/use, disordered eating, unprotected sexual intercourse, and overweight/obesity, among others. Consider, for example, adolescent pregnancy, which has serious adverse consequences for the mother, including curtailing her educational attainment, which constrains her life chances and predicts worse health in adulthood (AHRQ, 2003)
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For example, poor neighborhood conditions (e.g., substandard housing and excess community violence) are associated with inferior health status (Diez Roux and Mair, 2010; Miller et al., 2011)
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Figure 2-2 illustrates the behavioral and social determinants of health across the life course, tying together the important concepts described above. Measuring Health for Children and Adolescents Changing demographic trends among America's children and youth; new health problems in the general population; persistent health disparities; and dynamic interactions among health, health services, health influences, and child functioning all contribute to the need for timely and accurate data systems that can document the health of children and adolescents.
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Many existing health data sets offer useful snapshots of specific conditions and selected populations, such as the number and geographic or age distribution of children with diabetes or asthma, or the ages and gender of adolescents who engage in unhealthy behaviors such as underage drinking, risky driving, or substance abuse. However, the nation lacks the capacity to identify and monitor sig
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While this model is particularly useful in assessing the performance of health care services in meeting the needs of children and adolescents with special health care needs, as well as assessing the value and effectiveness of preventive services offered to general populations of children and adolescents in clinical settings, it may have limited value in determining the level of unmet health or health care needs of selected populations. Health care quality measures can address such questions as • A re immunization programs effective in protecting children and adolescents from infectious disease?
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Such data can also be derived from population health surveys of providers, patients, or their families. While multiple measures of health care quality are currently available, measures that rely heavily on abstraction from medical records are costly and are not feasible for use in large-scale data sets.
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59) The population health emphasis on intermediate and distal determinants of health, such as those that are influenced by social and economic factors or individual behaviors, is now beginning to shape the types of data that are collected within health care quality data sets as well.
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And those who want to achieve better health outcomes for patients who depend on public health plans will emphasize the need to monitor the health status and quality of care for groups of patients with similar health conditions in ways that can support analyses and help identify opportunities for interventions at the regional and national levels. Although each of these efforts draws on different data sources for different objectives, they all share a common interest in using data and indicators to drive improvements in the performance of the health care system.
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Within a life-course framework, it is also reasonable to ask whether early prevention services financed by Medicaid or CHIP can reduce long-term Medicare costs by preventing avoidable health conditions in the nation's aging population. Certain criteria need to be defined in developing such a high-quality child health data system.
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. Challenges to Creating a High-Quality Data System for Child and Adolescent Health and Health Care Quality Evidence indicates that the health care system in the United States is underperforming for children and that, as discussed above, considerable variation exists in access to care, care quality, and health outcomes (Kavanagh et al., 2009; Mangione-Smith et al., 2007; Schuster et al., 2005)
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. Yet several persistent challenges must be met in creating a high-quality data system for child health and health care quality.
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. Because of the limitations posed by the availability of evidence, HHS's initial core set of children's health care quality measures includes only two measures directly related to mental/behavioral health (i.e., follow-up after hospitalization for mental illness and follow-up care for children prescribed attention-deficit/hyperactivity disorder [ADHD]
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A substantial body of research also documents a range of deleterious effects that language barriers can have on the health and health care quality of children and adolescents, including inferior medical and oral health status; greater odds of having no medical or dental insurance; a lower likelihood of having a usual source of medical care; and impaired patient understanding of diagnoses, medications, and follow-up (Baker et al., 1996; Burbano O'Leary et al., 2003; Crane, 1997; Flores and Tomany-Korman,
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. An emerging literature points to the value of considering additional variables when assessing disparities in health care quality, access, and outcomes among children and adolescents.
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This lack of awareness may lead to inaccurate reporting or underreporting of risk behaviors and/or health conditions. INITIAL OBSERVATIONS ON CURRENT DATA SYSTEMS ADDRESSING CHILD AND ADOLESCENT HEALTH AND HEALTH CARE The committee recognized from the outset of this study that in efforts to address important issues related to child and adolescent health status, health care access and quality, and outcomes of care, attention must be paid to decades-old problems within the data collection and reporting systems.
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. Research has shown that low levels of functional health literacy are associated with increased hospitalizations, greater use of emergency services, lower likelihood of obtaining preventive vaccinations, diminished ability to read and comprehend prescription labels and health messages, poorer oral health status, and lower likelihood of enrolling in social welfare programs designed to improve child health and family well-being (AHRQ, 2011; Mejia et al., 2010; Miller et al., 2010; Pati et al., 2010)
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. In embarking on its charge, however, the committee noted that, despite the focus of the earlier IOM report on child health status and the multidimensional factors that, together, influence health status, the diagram in Figure 2-1 does not illustrate the complexities associated with interactions between health care services and interventions and health outcomes.
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This effort would need to identify not only measures of evidence-based health care services but also the extent to which such services were available or provided in an effective manner to the appropriate populations of children and adolescents, including indicators of overuse and underuse of such services. Including these types of data system components would represent an extension of the four major categories of influence on child and adolescent health depicted in the diagram from the earlier IOM study, Children's Health, the Nation's Wealth (Figure 2-1)
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and introduce even greater complexity, cost, and anticipated difficulties in implementation. In its deliberations, the committee assumed that an important outcome of its efforts would be the promulgation of one or more conceptual models for a comprehensive data system for child and adolescent health and health care quality.
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An important initial step in enabling immediate progress toward a national approach to child and adolescent health and health care quality data was undertaken by an expert advisory panel convened by AHRQ. This panel, known as the Subcommittee of the National Advisory Committee (SNAC)
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The improved measures will need to address the availability of and access to health care services, the utilization and quality of health and health care services and their underlying processes, and the outcomes associated with their use. Initial observations about the current state of measurement of child and adolescent health and health care quality suggest that conceptual work is necessary to organize data on child and adolescent health and health care quality; to identify priority goals in these areas; to reach consensus on valid and feasible measures for these goals; and to standardize reporting of these measures in federal, state, and local reports.
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